Complications in Head and Neck Surgery — MCQs

10 questions

One of the most important complication of tracheostomy is:

A patient has a lacerated, untidy wound of the leg and attended the casualty department after 2 hours. His wound should be:

Frey's syndrome is associated with-

Early complications of Tracheostomy are all EXCEPT

Which of the following statements is false regarding postpartum hemorrhage and pelvic hematomas?

Reactionary Hemorrhage occurs due to?

Carcinoma of pyriform fossa usually presents with :

In patient of head injuries with rapidly increasing intracranial tension without hematoma, the drug of choice for initial management would be :

Which of the following is not directly implicated as a cause of squamous cell carcinoma of the head and neck?

Q10

Burns involving the head and neck region are particularly dangerous because :

Complications in Head and Neck Surgery Indian Medical PG Practice Questions and MCQs

Question 1: One of the most important complication of tracheostomy is:

A. Hemorrhage
B. Surgical emphysema
C. Displacement of tube (Correct Answer)
D. Recurrent laryngeal nerve palsy

Explanation: ***Displacement of tube*** - **Accidental decannulation** or displacement of the tracheostomy tube is considered one of the most serious and common complications, particularly in the immediate post-operative period. - This can lead to **loss of airway**, requiring immediate intervention to prevent severe hypoxia and potential brain injury or death. *Hemorrhage* - While hemorrhage can occur during or after tracheostomy, it is often a concern during the procedure or in the immediate postoperative period and is usually managed effectively. - Significant, life-threatening hemorrhage such as **tracheo-innominate fistula** is a rare but severe complication. *Surgical emphysema* - Surgical emphysema (subcutaneous emphysema) is a relatively common but usually benign complication that occurs when air leaks from the trachea into the subcutaneous tissues. - It typically resolves spontaneously and rarely poses a direct threat to the airway unless severe and rapidly progressive. *Recurrent laryngeal nerve palsy* - **Recurrent laryngeal nerve injury** is a rare complication of tracheostomy, as the nerve is usually well clear of the incision site in the neck. - While it can cause hoarseness or vocal cord paralysis, it typically does not present an immediate life-threatening situation or emergency comparable to airway compromise.

Question 2: A patient has a lacerated, untidy wound of the leg and attended the casualty department after 2 hours. His wound should be:

A. Debrided and sutured immediately
B. Sutured immediately
C. Cleaned and dressed
D. Debrided and sutured secondarily (Correct Answer)

Explanation: ***Debrided and sutured secondarily*** - An **untidy wound** indicates contamination, irregular edges, and devitalized tissue, which significantly increases the **risk of wound infection**. - The standard management involves **thorough debridement** to remove all contaminated and non-viable tissue, followed by **delayed primary closure** (suturing after 3-5 days once the wound shows healthy granulation) or **healing by secondary intention**. - This approach is especially important for **lower extremity wounds**, which have a higher infection risk due to relatively poorer blood supply compared to facial wounds. - Even though the patient presented within 2 hours (well within the "golden period"), the **untidy nature** of the wound makes **immediate primary closure risky** and secondary closure the safer, preferred option. *Debrided and sutured immediately* - While **debridement is essential** for untidy wounds, **immediate primary closure** after debridement is generally reserved for **tidy wounds** with minimal contamination. - For untidy wounds, immediate closure increases the risk of **trapping bacteria and devitalized tissue**, leading to **wound infection**, abscess formation, or dehiscence despite being within the golden period. - Primary closure may be considered in select cases with minimal contamination and excellent debridement, but this is not the standard teaching for untidy wounds. *Sutured immediately* - **Immediate suturing without debridement** of an untidy wound would be dangerous, as it would trap contaminants, foreign material, and devitalized tissue. - This approach would significantly increase the risk of **serious wound infection**, including **gas gangrene** or necrotizing fasciitis in contaminated wounds. - Proper wound preparation is mandatory before any closure is considered. *Cleaned and dressed* - Simple **cleaning and dressing** is insufficient for an untidy wound as it does not address the devitalized tissue that requires **surgical debridement**. - While this avoids the risk of premature closure, it fails to provide adequate treatment for a wound that needs formal surgical debridement to remove non-viable tissue and reduce bacterial load. - This approach might be acceptable only as a temporary measure if surgical debridement cannot be performed immediately.

Question 3: Frey's syndrome is associated with-

A. Motor fibres of facial nerve
B. Parasympathetic fibres of auriculo temporal nerve (Correct Answer)
C. Sympathetic fibres of auriculo temporal nerve
D. Parasympathetic fibres of trigeminal nerve

Explanation: ***Parasympathetic fibres of auriculo temporal nerve*** - **Frey's syndrome**, or **gustatory sweating**, occurs due to aberrant regeneration of damaged **auriculotemporal nerve fibers** after **parotid gland surgery** or trauma. - **Parasympathetic secretomotor fibers** that originally innervated the **parotid gland** mistakenly reinnervate overlying **sweat glands** and **blood vessels** of the skin. *Motor fibres of facial nerve* - **Motor fibers of the facial nerve** control **facial expression muscles** and are not directly involved in the pathogenesis of Frey's syndrome. - Damage to these fibers would result in **facial paralysis**, not gustatory sweating. *Sympathetic fibres of auriculo temporal nerve* - The **auriculotemporal nerve** contains **sensory fibers** to the temporal region and **parasympathetic secretomotor fibers** to the parotid gland, but its sympathetic fibers are primarily **vasomotor**. - **Sympathetic fibers** control vasoconstriction and eccrine sweating generally, but their aberrant regeneration is not the cause of Frey's syndrome. *Parasympathetic fibres of trigeminal nerve* - The **trigeminal nerve** is primarily **sensory** to the face and **motor** to the muscles of mastication; it does not directly innervate the parotid gland. - **Parasympathetic innervation** to the parotid gland is carried by the glossopharyngeal nerve via the otic ganglion, not the trigeminal nerve.

Question 4: Early complications of Tracheostomy are all EXCEPT

A. Pneumothorax
B. Apnoea
C. Haemorrhage
D. Stenosis (Correct Answer)

Explanation: ***Stenosis*** - **Stenosis** (tracheal or subglottic) is a **late complication** of tracheostomy, typically developing **weeks to months** after the procedure due to scar tissue formation - Results from **granulation tissue** at the stoma site, trauma from the tracheostomy tube, or prolonged cuff inflation - Requires long-term follow-up and may need intervention with dilation or surgical correction *Pneumothorax* - **Early and acute complication** occurring during or immediately after tracheostomy - Caused by accidental puncture of the **pleura** during incision or dissection, especially in patients with a high-riding pleura or short neck - Requires immediate recognition with chest X-ray and management (chest tube if significant) *Apnoea* - **Early complication** occurring shortly after tracheostomy placement - Particularly seen in patients with **chronic respiratory failure** and CO2 retention when there is sudden reduction in **PaCO2** - Mechanism: Removal of upper airway resistance and improved ventilation leads to rapid CO2 washout, suppressing the hypercapnic respiratory drive *Haemorrhage* - Common **early complication** occurring during the procedure or within the **first 24-48 hours** - Can range from minor oozing to severe bleeding from thyroid vessels, anterior jugular veins, or rarely the innominate artery - Early bleeding usually from small vessels; late bleeding (>48 hours) may indicate tracheo-innominate fistula

Question 5: Which of the following statements is false regarding postpartum hemorrhage and pelvic hematomas?

A. The vulva is the most common site for pelvic hematoma. (Correct Answer)
B. Hematomas less than 5 cm can often be managed conservatively.
C. Uterine atony is the most common cause of postpartum hemorrhage.
D. The most common artery to form a vulvar hematoma is the pudendal artery.

Explanation: ***The vulva is the most common site for pelvic hematoma.*** - While vulvar hematomas are common, the **vagina is actually the most common site** for puerperal hematomas. - **Retroperitoneal hematomas** are the least common but most dangerous type, often associated with a higher mortality rate due to delayed diagnosis. *Hematomas less than 5 cm can often be managed conservatively.* - **Small, stable hematomas** (typically less than 2-5 cm) that are not expanding can often be managed with observation, pain control, and ice packs. - Close monitoring for continued bleeding, signs of infection, or hemodynamic instability is crucial even with conservative management. *Uterine atony is the most common cause of postpartum hemorrhage.* - **Uterine atony** (failure of the uterus to contract after birth) accounts for approximately 70-80% of all cases of postpartum hemorrhage. - This condition leads to excessive bleeding from the placental site due to the inability of uterine muscle fibers to compress blood vessels effectively. *The most common artery to form a vulvar hematoma is the pudendal artery.* - Vulvar hematomas primarily arise from injury to branches of the **pudendal artery**, particularly during lacerations or episiotomies. - Trauma to the **perineum** during childbirth can cause these arteries or their venous counterparts to bleed into the surrounding loose connective tissue.

Question 6: Reactionary Hemorrhage occurs due to?

A. Infection
B. Damage to a blood vessel
C. Pressure necrosis
D. Dislodgement of clot (Correct Answer)

Explanation: ***Dislodgement of clot*** - **Reactionary hemorrhage** occurs within the first 24 hours post-surgery as the initial **vasoconstriction** and **blood pressure drop** from anesthesia resolve. - As blood pressure normalizes and peripheral vessels dilate, a **clot** that formed in a previously bleeding vessel becomes dislodged, leading to bleeding. *Infection* - **Infection** can cause secondary hemorrhage, but this typically occurs later, usually several days to weeks after surgery, due to tissue necrosis and erosion of blood vessels. - It is not the primary mechanism for hemorrhage occurring within the first 24 hours. *Damage to a blood vessel* - **Damage to a blood vessel** during surgery is a cause of primary hemorrhage, which occurs during or immediately after the procedure. - While it initiates the potential for bleeding, reactionary hemorrhage specifically refers to bleeding that resumes due to changes in patient physiology post-operatively, rather than ongoing vessel damage. *Pressure necrosis* - **Pressure necrosis** refers to tissue death due to sustained external pressure, often leading to skin breakdown or deep tissue injury. - It does not directly cause reactionary hemorrhage, although necrotic tissue could potentially contribute to later secondary hemorrhage if a vessel erodes.

Question 7: Carcinoma of pyriform fossa usually presents with :

A. Lump in the neck
B. Cough
C. Dysphagia (Correct Answer)
D. Hoarseness

Explanation: ***Dysphagia*** - Carcinoma of the **pyriform fossa** is a type of hypopharyngeal cancer, and given its anatomical location, it commonly interferes with swallowing [1]. - The pyriform fossa lies immediately lateral to the laryngeal inlet, and involvement here directly impacts the ability to form a **food bolus** and propel it into the esophagus. *Lump in the neck* - A neck lump can occur, especially if there is **lymph node metastasis**, but it's often a later symptom [1]. - **Dysphagia** usually precedes the development of a palpable neck mass as the primary tumor expands within the pyriform fossa [1]. *Cough* - While aspiration might lead to coughing, it's not the primary presenting symptom. - Cough is more commonly associated with laryngeal involvement or **tracheal invasion**, which can occur with advanced disease. *Hoarseness* - **Hoarseness** is a prominent symptom if the **vocal cords** or recurrent laryngeal nerve are directly involved [2]. - The pyriform fossa is adjacent but distinct from the vocal cords, so hoarseness is not typically the initial or most common symptom unless the tumor extends medially.

Question 8: In patient of head injuries with rapidly increasing intracranial tension without hematoma, the drug of choice for initial management would be :

A. 20% Mannitol (Correct Answer)
B. Lasix
C. Glycine
D. Steroids

Explanation: ***20% Mannitol*** - **Mannitol** is an osmotic diuretic that reduces **intracranial pressure (ICP)** by creating an osmotic gradient, drawing water from the brain parenchyma into the intravascular space [1]. - Its rapid onset of action and significant ICP-reducing effects make it the drug of choice for acute management of elevated ICP in head injuries without hematoma. *Lasix* - **Furosemide (Lasix)** is a loop diuretic that can reduce ICP by decreasing cerebrospinal fluid production and promoting diuresis. - However, its effects are generally slower and less potent than mannitol for acute, rapidly increasing ICP. *Glycine* - **Glycine** is an amino acid and neurotransmitter; it has no direct role in the acute management of increased ICP. - It is sometimes used as an irrigating solution in urological procedures but is not indicated for brain injury. *Steroids* - **Steroids**, particularly **dexamethasone**, are effective in reducing vasogenic edema associated with brain tumors or abscesses. - They are generally **not recommended** for acute traumatic brain injury due to lack of benefit and potential for increased mortality or complications.

Question 9: Which of the following is not directly implicated as a cause of squamous cell carcinoma of the head and neck?

A. EBV
B. HPV
C. Betel Nut
D. Vitamin A deficiency (Correct Answer)

Explanation: ***Vitamin A*** - Vitamin A deficiency is associated with increased risk of squamous metaplasia but not a direct cause of squamous cell carcinoma in the head and neck. - Adequate levels of Vitamin A are actually protective against various epithelial cancers. *EBV* - Epstein-Barr Virus (EBV) is linked to certain types of cancers, including nasopharyngeal carcinoma, but is not a major causative factor for squamous cell carcinoma [1]. - It can contribute to **lymphoproliferative disorders** but not primarily to squamous cell carcinoma of the head and neck [1]. *HPV* - Human Papillomavirus (HPV), particularly types 16 and 18, are recognized as significant contributors to oropharyngeal squamous cell carcinoma [1]. - HPV infection can lead to **malignant transformation** of epithelial cells [1]. *Betel Nut* - Betel nut chewing is a well-established risk factor for oral squamous cell carcinoma, associated with its carcinogenic properties [2]. - It can cause **oral lesions** and dysplasia, contributing significantly to the etiology of head and neck cancers [2].

Question 10: Burns involving the head and neck region are particularly dangerous because :

A. Face is a very vascular area
B. Renal failure is more frequent
C. Blood loss may be more severe
D. There may be thermal damage to the respiratory passage (Correct Answer)

Explanation: ***There may be thermal damage to the respiratory passage*** - Burns to the **head and neck** often indicate exposure to heat or flame around the face, increasing the risk of inhaling hot air, smoke, or toxic fumes. - This can lead to **thermal damage** to the upper and lower **respiratory passages**, causing edema, airway obstruction, and acute respiratory distress. *Face is a very vascular area* - While the face is indeed **vascular**, this property primarily impacts **healing time** (often faster due to good blood supply) and the potential for swelling, but does not inherently make burns in this region "particularly dangerous" in the immediate, life-threatening sense compared to airway compromise. - The vascularity itself doesn't directly cause a unique danger that surpasses the risk of **airway obstruction** or systemic complications. *Renal failure is more frequent* - **Acute renal failure** can be a complication of severe burns due to hypovolemia, rhabdomyolysis, or sepsis, but it is not specific to burns of the head and neck region. - It is a systemic complication related to the overall burn severity and total body surface area (TBSA) involved, rather than the specific anatomical location of the burn. *Blood loss may be more severe* - Significant **blood loss** is not typically a direct primary concern in burn injuries unless there are associated trauma or very deep burns to highly vascular areas. - While fluid shifts in burns can be massive, initial blood loss is not the defining factor that makes head and neck burns particularly dangerous from a life-threatening perspective.

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